Infrapopliteal revascularization in diabetic foot ischemia: correlation between morphologic and clinical results

ABSTRACT Purpose: To retrospectively evaluate angiographic and clinical outcomes of percutaneous revascularization in diabetic patients with Fontaine stage IV critical limb ischemia (CLI). Materials and Methods: Clinical and procedural data were retrospectively collected of consecutive diabetic patients with Fontaine stage IV CLI who underwent percutaneous limb revascularization from January 2009 to June 2011. Pre- and post-procedural angiographic images were retrospectively reviewed to classify lower limb arterial involvement according to 3 systems: 1) TASC II; 2) Graziani’s morphological classification; 3) Joint Vascular Society Council calf and foot scores. Foot lesions were graded according to the Texas University (TU) classification. Clinical results (healing, stability or major amputation) were compared to baseline clinical data and angiographic results. Results: In the study period, 202 percutaneous procedures were performed, with an immediate technical success rate of 93.6%. The majority of ulcers (75.7%) were deep (TU grades 2 and 3). Mean preprocedural calf and foot scores were 7.81.6 and 7.32.3, respectively; 132 patients (65.3%) were in Graziani’s morphological classes from 4 to 7 (at least two arteries occluded); in 112 (55.4%) cases TASC II was inapplicable (only infrapopliteal involvement). After the procedure, mean calf and foot scores were 4.82.3 and 5.92.6, respectively, and 86.6% of cases were into the Graziani’s classes 1 and 2, whereas TASC II was inapplicable in all cases. Healing rate was 66.8% and major amputation rate was 3.9%. Among all the clinical and angiographic variables included in the analysis, only pre- and post-procedural foot scores were significantly associated to the clinical outcome (p=0.04). Conclusion: TASC II is inadequate to describe vascular involvement in the vast majority of diabetic patients with CLI. In this population, percutaneous revascularization should represent the first-line treatment option, leading to high healing and limb salvage rates. Pre- and post-procedural foot scores significantly affect chances of healing, thus aggressive treatment of foot arteries should be attempted whenever possible